Download SAUNDERS NCLEX-RN MENTAL HEALTH REVIEW QUESTIONS AND ANSWERS UPDATED 2024/2025 RATED A+ FO and more Exams Nursing in PDF only on Docsity! SAUNDERS NCLEX-RN MENTAL HEALTH REVIEW QUESTIONS AND ANSWERS UPDATED 2024/2025 RATED A+ FOR SUCCESS A client admitted voluntarily for treatment of an anxiety disorder demands to be released from the hospital. Which of the following actions should the nurse take immediately? 1. Contact the client's HCP 2. Call the client's family to arrange for transportation. 3. Attempt to persuade the client to stay for "only a few more days." 4. Tell the client that leaving would likely result in an involuntary commitment. - CORRECT ANSWERS 1. Contact the client's HCP When reviewing the admission assessment, the nurse notes that a client was admitted to the mental health unit involuntarily. Based on this type of admission, the nurse should provide which intervention for this client? 1. Monitor closely for harm to self or others 2. Assist in completing an application for admission 3. Supply the client with written information about their mental illness 4. Provide an opportunity for the family to discuss why they felt the admission was needed. - CORRECT ANSWERS 1. Monitor closely for harm to self or others The nurse employed in a mental health clinic is greeted by a neighbor in a local grocery store. The neighbor says to the nurse, "How is Carol doing? She is my best friend and is seen at your clinic every week." Which is the most appropriate nursing response? 1. "I cannot discuss any client situation with you." 2. "If you want to know about Carol, you need to ask her herself." 3. "Only because you're worried about a friend, I'll tell you that she is improving." 4. "Being her friend, you know she is having a difficult time and deserved her privacy." - CORRECT ANSWERS 1. "I cannot discuss any client situation with you." The nurse calls security and has physical restraints applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged SAUNDERS NCLEX-RN MENTAL HEALTH REVIEW QUESTIONS AND ANSWERS UPDATED 2024/2025 RATED A+ FOR SUCCESS from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select all that apply. A. Libel B. Battery C. Assault D. Slander E. False Imprisonment - CORRECT ANSWERS B. Battery C. Assault E. False Imprisonment The nurse in the mental health unit recognizes which as being therapeutic communication techniques? Select all that apply. 1. Restating 2. Listening 3. Asking the client, "Why?" 4. Maintaining neutral responses 5. Providing acknowledgement and feedback 6. Giving advice and approval or disapproval - CORRECT ANSWERS 1. Restating 2. Listening 4. Maintaining neutral responses 5. Providing acknowledgement and feedback The nurse is working with a client who despite making a heroic effort was unable to rescue a neighbor trapped in a house fire. Which client-focused action should the nurse engage in during the working phase of the nurse-client relationship? 1. Exploring the client's ability to function. 2. Exploring the client's potential for self-harm. 3. Inquiring about the client's perception or appraisal of why the rescue was unsuccessful. SAUNDERS NCLEX-RN MENTAL HEALTH REVIEW QUESTIONS AND ANSWERS UPDATED 2024/2025 RATED A+ FOR SUCCESS 2. Sharing personal preference regarding food choices 3. Documenting reasons why the client does not want to eat. 4. Offering opinions about the necessity of adequate nutrition. - CORRECT ANSWERS 1. Using open ended questions and silence The nurse would plan which goals for the termination stage of group development? SATA. - CORRECT ANSWERS 1. The group evaluates the experience 6. The group explores members' feelings about the group and the impending separation. A client diagnosed with terminal cancer says to the nurse, "I'm going to die and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I'm the one who's dying." Which response by the nurse is therapeutic? 1. "Have you shared your feelings with your family?" 2. "I think we should talk more about your anger with your family." 3. "It sounds as if you are feeling angry that your family continues to hope for you to be cured?" 4. "You are probably very depressed, which is understandable with such a diagnosis." - CORRECT ANSWERS 3. "It sounds as if you are feeling angry that your family continues to hope for you to be cured?" On review of the client's record, the nurse notes that the mental health admission was voluntary. Based on this information, the nurse anticipates which client behavior? 1. Fearfulness regarding treatment measures. 2. Anger and aggressiveness directed toward others. 3. An understanding of the pathology and symptoms of the diagnosis. 4. A willingness to participate in the planning of the care and treatment plan. - CORRECT ANSWERS 4. A willingness to participate in the planning of the care and treatment plan. The nurse is caring for a client who is experiencing disturbed thought processes as a result of paranoia. In formulating nursing interventions with the members of the health care team, what best instruction would the nurse provide to the staff? SAUNDERS NCLEX-RN MENTAL HEALTH REVIEW QUESTIONS AND ANSWERS UPDATED 2024/2025 RATED A+ FOR SUCCESS 1. Increase socialization of the client with peers 2. Avoid using a whispering voice in front of the client 3. Begin to educate the client about social supports in the community. 4. Have the client sign a release of information to appropriate parties for assessment purposes. - CORRECT ANSWERS 2. Avoid using a whispering voice in front of the client The nurse is caring for a client diagnosed with catatonic stupor who is lying on the bed in a fetal position. What is the most appropriate nursing intervention? 1. Ask direct questions to encourage talking. 2. Leave the client alone so as to minimize external stimuli 3. Sit beside the client in silence with occasional open-ended questions. 4. Take the client into the dayroom with other clients so that they can help watch him. - CORRECT ANSWERS 3. Sit beside the client in silence with occasional open-ended questions. The nurse is preparing a client with a history of command hallucination for discharge by providing instructions on interventions for managing hallucinations and anxiety. Which statement in response to these instructions suggest to the nurse that the client has a need for additional information? - CORRECT ANSWERS "When I have command hallucinations, Ill call a friend for help" The nurse observes that a client is pacing, agitated, and presenting aggressive gestures. The client's speech pattern is rapid, and affect is belligerent. Based on the observations, what is the nurse's immediate priority of care? 1. Provide safety for the client and other clients on the unit 2. Provide the clients on the unit with a sense of comfort and safety 3. Assist the staff in caring for the client in a controlled environment 4. Offer the client a less stimulating area to calm down in and gain control. - CORRECT ANSWERS 1. Provide safety for the client and other clients on the unit SAUNDERS NCLEX-RN MENTAL HEALTH REVIEW QUESTIONS AND ANSWERS UPDATED 2024/2025 RATED A+ FOR SUCCESS Which nursing interventions are appropriate for a hospitalized client with mania who is exhibiting manipulative behavior? Select all that apply. 1. Communicate expected behaviors to the client 2. Ensure that the client knows that they are not in charge of the nursing unit. 3. Assist the client in identifying ways of setting limits on personal behaviors. 4. Follow through about the consequences of behavior in a nonpunitive manner. 5. Enforce rules by informing the client that they will not be allows to attend therapy groups. 6. Have the client state the consequences for behaving in ways that are viewed as unacceptable. - CORRECT ANSWERS 1,3,4,6 1. Communicate expected behaviors to the client 3. Assist the client in identifying ways of setting limits on personal behaviors. 4. Follow through about the consequences of behavior in a nonpunitive manner. 6. Have the client state the consequences for behaving in ways that are viewed as unacceptable. The nurse is conducting a group therapy session. During the session, client diagnosed with mania consistently disrupts the group's interactions. Which intervention should the nurse initially implement? 1. Setting limits on the client's behaviors 2. Asking the client to leave the group session 3. Asking another nurse to escort the client out of the group session 4. Telling the client that they will not be able to attend any future group sessions. - CORRECT ANSWERS 1. Setting limits on the client's behaviors A client is admitted to a medical nursing unit with a diagnosis of acute blindness after being involved in a hit-and-run accident. When diagnostic testing cannot identify any organic reason why this client cannot see, a mental health consult is prescribed. Which condition will be the focus of this consult? 1. Psychosis SAUNDERS NCLEX-RN MENTAL HEALTH REVIEW QUESTIONS AND ANSWERS UPDATED 2024/2025 RATED A+ FOR SUCCESS 6. maintain NPO status - CORRECT ANSWERS 1. monitor vital signs 2. provide a safe environment 3. address hallucinations therapeutically 5. provide reality orientation as appropriate The nurse determines that the wife of an alcoholic client is benefiting from attending an Al- Anon group if the nurse hears the wife make which statement? 1. "i no longer feel that i deserve the beatings my husband inflicts on me" 2. "my attendance at the meetings has helped me to see that i provoke my husband's violence" 3. "i enjoy attending the meetings because they get me out of the house and away from my husband" 4. "i can tolerate my husband's destructive behaviors now that i know they are common among alcoholics" - CORRECT ANSWERS 1. "i no longer feel that i deserve the beatings my husband inflicts on me" A hospitalized client with a history of alcohol abuse tells the nurse "i am leaving now, i have to go. I don't want any more treatment. I have things that i have to do right away." The client has not been discharged and is scheduled for an important diagnostic test to be performed in 1 hour. After the nurse discusses the client's concerns with the client, the client dresses and begins to walk out of the hospital room. What action should the nurse take? 1. call the nursing supervisor 2. call security to block all exit areas 3. restrain the client until the HCP can be reached 4. tell the client that the client cannot return to this hospital again if the client leaves now - CORRECT ANSWERS 1. call the nursing supervisor The nurse is preparing to perform an admission assessment on a client with a diagnosis of bulimia nervosa. Which assessment findings should the nurse expect to note? Select all that apply. 1. dental decay SAUNDERS NCLEX-RN MENTAL HEALTH REVIEW QUESTIONS AND ANSWERS UPDATED 2024/2025 RATED A+ FOR SUCCESS 2. moist, oily skin 3. loss of tooth enamel 4. electrolyte imbalances 5. body weight well below ideal range - CORRECT ANSWERS 1. dental decay 3. loss of tooth enamel 4. electrolyte imbalances The nurse is caring for a female client who was admitted to the mental health unit recently for anorexia nervosa. The nurse enters the client's room and notes that the client is engaged in rigorous push-ups. Which nursing action is most appropriate? 1. allow the client to complete her exercise program 2. interrupt the client and weigh her immediately 3. tell the client that she is not allowed to exercise rigorously 4. interrupt the client and offer to take her for a walk - CORRECT ANSWERS 4. interrupt the client and offer to take her for a walk The nurse is monitoring a hospitalized client who abuses alcohol. Which findings should alert the nurse to the potential for alcohol withdrawal delirium? 1. hypotension, ataxia, hunger 2. stupor, lethargy, muscle rigidity 3. hypotension, coarse hand tremors, lethargy 4. hypertension, changes in level of consciousness, hallucinations - CORRECT ANSWERS 4. hypertension, changes in level of consciousness, hallucinations A client with a diagnosis of anorexia nervosa, who is in a state of starvation, is in a 2-bed room. A newly admitted client will be assigned to this client's room. Which client would be the best choice as a roommate for the client with anorexia nervosa? 1. a client with pneumonia 2. a client undergoing diagnostic tests 3. a client who thrives on managing others SAUNDERS NCLEX-RN MENTAL HEALTH REVIEW QUESTIONS AND ANSWERS UPDATED 2024/2025 RATED A+ FOR SUCCESS 4. a client who could benefit from the client's assistance at mealtime - CORRECT ANSWERS 2. a client undergoing diagnostic tests The spouse of a client admitted to the mental health unit for alcohol withdrawal says to the nurse, "i should get out of this bad situation." Which is the most helpful response by the nurse? 1. "why don't you tell your spouse about this?" 2. "what do you find difficult about this situation?" 3. "this is not the best time to make that decision" 4. "i agree with you. you should get out of this situation" - CORRECT ANSWERS 2. "what do you find difficult about this situation?" A client with anorexia nervosa is a member of a pre-discharge support group. The client verbalizes that she would like to buy some new clothes, but her finances are limited. Group members have brought some used clothes to the client to replace the client's old clothes. The client behaves that the new clothes are much too tight and has reduced her calorie intake to 800 calories daily. How should the nurse evaluate this behavior? 1. normal behavior 2. evidence of the client's disturbed body image 3. regression as the client is moving toward the community 4. indicative of the client's ambivalence about hospital discharge - CORRECT ANSWERS 2. evidence of the client's disturbed body image